COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of the Anglican Education Commission (Anglican EdComm) pursuant to Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Author: Todd Love, Christian Laier, Matthias Brand, Linda Hatch & Raju Hajela Title of Article: Neuroscience of Internet Pornography Addiction: A Review and Update Title of Journal: Behavioural Sciences Edition (Year):Page Vol.5 Issue 3 (2015): 388-433 CAL LICENSED COPY. UNAUTHORISED COPYING PROHIBITED. Behav. Sci. 2015, 5, 388-433; doi:10.3390/bs5030388 OPEN ACCESS behavioral sciences ISSN 2076-328X www.mdpi.com/journal/behavsci/ Review Neuroscience of Internet Pornography Addiction: A Review and Update Todd Love 1,†,*, Christian Laier 2,†, Matthias Brand 2,3,†, Linda Hatch 4,† and Raju Hajela 5,6,† 1 Society for the Advancement of Sexual Health, Ardmore, PA 19003, USA 2 Department of General Psychology: Cognition, University of Duisburg-Essen, Duisburg 47057, Germany; E-Mails: [email protected] (C.L.); [email protected] (M.B.) 3 Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen 45141, Germany 4 Private Practice, Santa Barbara, CA 93103, USA; E-Mail: [email protected] 5 Health Upwardly Mobile Inc., Calgary, AB T2S 0J2, Canada; E-Mail: [email protected] 6 Diagnostic and Descriptive Terminology Action Group (DDTAG), American Society of Addiction Medicine (ASAM), Chevy Chase, MD 93101, USA † These authors contributed equally to this work. * Author to whom correspondence should be addressed; E-Mail: [email protected]; Tel.: +1-706-383-7401. Academic Editor: Andrew Doan Received: 2 July 2015 / Accepted: 8 September 2015 / Published: 18 September 2015 Abstract: Many recognize that several behaviors potentially affecting the reward circuitry in human brains lead to a loss of control and other symptoms of addiction in at least some individuals. Regarding Internet addiction, neuroscientific research supports the assumption that underlying neural processes are similar to substance addiction. The American Psychiatric Association (APA) has recognized one such Internet related behavior, Internet gaming, as a potential addictive disorder warranting further study, in the 2013 revision of their Diagnostic and Statistical Manual. Other Internet related behaviors, e.g., Internet pornography use, were not covered. Within this review, we give a summary of the concepts proposed underlying addiction and give an overview about neuroscientific studies on Internet addiction and Internet gaming disorder. Moreover, we reviewed available neuroscientific literature on Internet pornography addiction and connect the results to the Behav. Sci. 2015, 5 389 addiction model. The review leads to the conclusion that Internet pornography addiction fits into the addiction framework and shares similar basic mechanisms with substance addiction. Together with studies on Internet addiction and Internet Gaming Disorder we see strong evidence for considering addictive Internet behaviors as behavioral addiction. Future research needs to address whether or not there are specific differences between substance and behavioral addiction. Keywords: internet pornography addiction; internet addiction; internet gaming disorder; neuroscience; neuroimaging; DSM-5; behavioral addiction; addictive behavior; cybersex; online sexual behavior 1. Introduction A revolutionary paradigm shift is occurring in the field of addiction that has great implications for assessment and treatment. While “addiction” has historically been associated with the problematic overconsumption of drugs and/or alcohol [1], the burgeoning neuroscientific research in this field has changed our understanding over the last few decades. It is now evident that various behaviors, which are repeatedly reinforcing the reward, motivation and memory circuitry are all part of the disease of addiction [2–10]. Common mechanisms among addiction involving various psychoactive substances such as alcohol, opioids and cocaine; and pathological behaviors such as uncontrolled gambling, internet use, gaming, pornography and sexual acting out have also been delineated. As a result of the growing neuroscientific evidence, the American Society of Addiction Medicine (ASAM) formally expanded their definition of addiction in 2011 to include both behaviors and substances: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors [11]. The American Psychiatric Association (APA) also acknowledged the phenomenon of behavioral addiction, as can be seen in multiple passages within the DSM-5. For example, the “Substance Related Disorders” chapter was renamed “Substance Use and Addictive Disorders”, a “Non-Substance-Related Disorders” subchapter was created, and perhaps most notably, Gambling Disorder (formerly named Pathological Gambling) was moved into this the newly formed subchapter, due to its “reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders” [12]. Further, a diagnosis of Internet Gaming Disorder (IGD) was placed within Section 3—Conditions for Further Study of the DSM-5. In support of this new diagnosis, the APA stated in their press release/fact sheet on IGD: The studies suggest that when these individuals are engrossed in Internet games, certain pathways in their brains are triggered in the same direct and intense way that a drug addict’s Behav. Sci. 2015, 5 390 brain is affected by a particular substance. The gaming prompts a neurological response that influences feelings of pleasure and reward, and the result, in the extreme, is manifested as addictive behavior [13]. This statement is supported by large amounts of neuroscientific research, as illustrated within this review. Unfortunately, the APA went on to make the following statement in the Differential Diagnosis section of IGD: Excessive use of the Internet not involving playing of online games (e.g., excessive use of social media, such as Facebook; viewing pornography online) is not considered analogous to Internet gaming disorder, and future research on other excessive uses of the Internet would need to follow similar guidelines as suggested herein [12]. This decision is inconsistent with existing and emerging scientific evidence, and the conducted review aims at contributing to the ongoing discussion of Internet pornography addiction (IPA) in response to the APA’s request. The APA has not clearly stated why the larger diagnosis, Internet Addiction (IA), was reworked into the more content specific diagnosis of IGD. This position is consistent with Davis’s [14] original concept of Specific Problematic Internet Use (SPIU), as well as Brand, Laier and Young’s [15] updated version of Specific Internet Addiction (SIA). This also matches Griffiths proposed differentiation between addictions to the Internet and addictions on the Internet [16]. An easier and perhaps more functional decision, however, would have been to maintain the proposed diagnosis of IA but simply require a subtype or specifier; gaming, pornography, social networking, shopping, etc. The exact same criteria, references, and most of the wording currently listed for IGD could have been kept, with only the word “behavior” used in lieu of the word “gaming”. Indeed, the original formal proposal for IA to be included in the DSM-5 incorporated the subtypes of instant messaging, pornography use, and video games [17], expanded later to include social networking [18]. This would have aligned the DSM-5 with what has, in fact, occurred in the field since its publication, namely, the continued scientific investigation into the broad range of potentially problematic behaviors involving Internet use. This inclusive approach has been proposed multiple times, both historically [17] and recently [19,20]. Conceptualizing IA as a generalized problem with more specific subtypes is ripe for formal reconsideration. There is a key element found throughout all internet-related experiences: The ability to maintain or heighten arousal with the click of a mouse or swipe of a finger. Attention to novelty (scanning for salient cues in the environment) furthers survival, and research shows that it activates the brain’s reward system [21]. Thus, the act of seeking (which would include surfing) triggers the reward system [22]. So do stimuli that violate expectations (positive or negative) [23], which is often found in today’s videogames and internet pornography. Some internet activities, because of their power to deliver unending stimulation (and activation of the reward system), are thought to constitute supernormal stimuli [24], which helps to explain why users whose brains manifest addiction-related changes get caught in their pathological pursuit. Nobel prize winning scientist Nikolaas Tinbergen [25] posited the idea of “supernormal stimuli”, a phenomenon wherein artificial stimuli can